Improper Single-Person Transfer of Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with paraplegia, muscle weakness, and contractures, who was dependent for transfers and unable to stand, was transferred from a wheelchair to bed by a single CNA using an inappropriate technique. The resident's care plan specified the need for assistance with locomotion, and the physical therapy discharge summary indicated that transfers required two or more helpers for safety. Despite these documented requirements, the CNA transferred the resident alone, lifting the resident under the arms and placing him in bed without assistance. The resident reported discomfort and stated that the CNA 'picks me up and throws me in the bed,' and that this had previously resulted in foot pain. Interviews with facility staff confirmed that the resident should have been transferred with a two-person assist for safety, and that it would be difficult and unsafe for one person to perform the transfer. The CNA involved was unable to explain how he determined it was appropriate to transfer the resident alone and could not articulate how he is informed of residents' assistance needs. Facility policies reviewed emphasized the importance of safe and efficient transfers based on residents' physical abilities and the need to provide care that maintains dignity and quality of life.